The largest randomized controlled trial in history to evaluate solutions to end chronic homelessness, this national project demonstrated the promise and value of the Housing First model in Canada.

The At Home/Chez Soi project (2009-13) involved more than 2,000 people who were homeless and living with mental illness in cities across the country. MAP led the Toronto arm. In 2015, results from the study helped to influence the province to set a goal to end chronic homelessness in Ontario within the next 10 years.

Housing First

‘Housing First’ offers rent supplements and case management support as a first step to recovery – rather than making this support contingent on participants seeking treatment for mental health problems or addictions.

Since At Home/Chez Soi began, Housing First has been increasingly adopted as a strategy to end chronic homelessness. However there are few studies that provide evidence on the long-term impacts of this approach. With an additional three years of follow-up data now complete from the Toronto site, we are able to look at the effects of Housing First on health, housing, and well-being over time.

What We’ve Learned

When the first follow-up stage of the project concluded in 2015, the results demonstrated that the At Home version of Housing First leads to housing stability for most people experiencing both homelessness and mental health problems.

In 2019, our first long-term analyses were published in this article. We found that:

• Participants who received Housing First spent more days stably housed, compared to participants who did not receive Housing First but had access to the usual services in the community.
• Homeless adults with a high need for mental health services benefit the most from Housing First. In the final year of follow up, six years after they entered the study, participants considered to have high need of support who received Housing First with ACT support spent 85% of days stably housed, compared with 60% for individuals who received treatment as usual.
• When we looked at measurements of how participants felt about their quality of life and their community activities, we found no differences over time between the groups of participants that received Housing First and those who did not. We also didn’t see differences between the two groups when we looked at the changes in the severity of their substance use over time.

What Are Our Next Steps?

We are continuing to analyze the Toronto data, to find out how Housing First affects participants in the long term, and what else needs to be considered beyond the Housing First supports to better address the needs of adults with mental illness who are exiting homelessness. We are currently focusing on the following topics:

• Food security
• Health care use
• Health and mental health outcomes
• Experiences of stigma and discrimination
• Risk factors for incarceration
• Long-term mortality outcomes and risk factors
• Traumatic brain injuries
• Cost effectiveness of the Housing First model

About the Study

The Toronto At Home/Chez Soi Study is part of a large Canadian multi-site randomized controlled trial of Housing First that took place in Toronto, Moncton, Montreal, Winnipeg and Vancouver. The study ran from 2009 to 2013 in all five sites, with additional follow up in Toronto from 2014 to 2017.

To participate, people needed to have significant histories of absolute homelessness and a diagnosable mental health problem.

MAP led the Toronto arm, where approximately 300 people were randomized to the intervention – in other words, they received Housing First as outlined below. Another approximately 270 people were randomized to ‘treatment as usual’ – services already available in Toronto.

We compared their outcomes such as mental health, quality of life and housing tenure (how long and how often people stayed housed) in these two groups over a seven year period.

People in the Toronto intervention arm received rent supplements of up to $600 a month. People with higher needs were assigned an Assertive Community Treatment Team. People with moderate needs were assigned a case manager.

The ‘At Home’ version of Housing First followed a model called ‘Pathways to Housing,’ originally developed in New York City. Key components include:

• Few pre-conditions. People are not required to seek treatment for mental health problems or addictions.
• Independent housing. People receive rent supplements, and are generally placed in independent, private market rental units.
• Housing that is separate from supports. Housing First supports are offsite – they are not tied to a building or unit. If people change their housing, supports will follow them.

Implementing Housing First

For a step-by-step guide to implementing Housing First, visit: housingfirsttoolkit.ca.

MAP’s recommendations for policy-makers, funders and people responsible for Housing First programs include:

• Urgently address the crisis related to the shortage of quality, affordable housing in Toronto – this presented a significant barrier to implementation for the At Home program, as highlighted in a study examining barriers to implementation over time.
• Once people are housed, address isolation through enhancements to the current program (e.g. additional peer support, life skills training, recreational and vocational opportunities).
• Invest in developing and maintaining relationships with landlords and working with people to maintain tenancies.
• Place a high priority on relationships between providers and participants, as strong, trusting alliances are associated with better outcomes.
• A commitment to anti-oppression/anti-racism is essential to program success and should include concrete measures. For example: hiring frontline and management staff representative of communities served.
• Housing First programs should include carefully-considered and appropriate adaptations for different groups of people and different settings. See examples from Toronto and Winnipeg.